An unfunded mandate
Under the Emergency Medical Treatment and Active Labor Act (EMTALA), emergency departments must screen and stabilize every patient who comes through the door. Emergency physicians provide that care around the clock, often without knowing whether, or how much, they’ll be paid.
That makes fair reimbursement all the more important. The No Surprises Act rightly keeps patients out of out-of-network billing disputes. But when an insurer’s payment falls short, Independent Dispute Resolution (IDR) gives emergency groups a fair, independent process to resolve it.
And that reimbursement has been under real pressure.
drop in out-of-network emergency physician payments from 2019 to 2022, steepest in the year the No Surprises Act took effect.1
drop in in-network emergency physician payments from 2019 to 2023.2
insurers’ own in-network rate compared with the QPA, in the 60.6% of IDR disputes where the QPA was below that rate.3
For emergency groups already operating under tight staffing and financial constraints, adequate payment for out-of-network claims isn’t just about the bottom line. It’s part of what keeps the local emergency department staffed at 2 a.m., especially in rural and underserved communities where access to care is already fragile.
With that much at stake, not to mention growing public scrutiny of IDR because of a handful of bad actors, emergency groups can’t afford to get the process wrong. This guide covers what emergency medicine groups need to know to do IDR right.
IDR done right means disputing only eligible claims, following the rules to the letter, and submitting payment offers you’d feel comfortable defending in front of a payor, a regulator, or a journalist.
Which claims are eligible for federal IDR?
Emergency care is among the clearest use cases for the No Surprises Act. The classic scenario is an out-of-network emergency physician treating a patient at an in-network hospital. But emergency-service protections also apply when the facility itself is out of network.
Is your claim eligible? Start with three questions.
Is the provider out of network?
The physician or physician group must lack an applicable in-network agreement with the patient’s health plan.
Is it a commercial insurance claim?
Government programs, including Medicare, Medicaid, Medicare Advantage, TRICARE, and VA care, are outside the IDR process.
Does the service qualify as emergency care?
For emergency medicine groups, this typically includes ED evaluation and management services (CPT
99283–99285) and critical care (CPT99291–99292).
The federal IDR process, step by step
IDR follows the same basic framework regardless of specialty. For emergency groups, the challenge isn’t understanding the steps and deadlines. It’s executing them at high claim volumes. Here’s how the federal process works today.
- Step 1
Initial payment or denial
The health plan has 30 calendar days after receiving a claim to issue an initial payment or notice of denial. Either party then has 30 business days from receipt to initiate open negotiation.
- 30 business days to initiate open negotiation
- Step 2
Open negotiation begins
Either party can initiate open negotiation by notifying the other. The 30-business-day negotiation period begins when the notice is sent.
It’s a chance to resolve the dispute without the added fees and administrative burden of IDR.
- 30 business days of open negotiation
- Step 3
Open negotiation ends
If the parties haven’t agreed on a payment amount by the end of the period, either party can initiate IDR.
- 4 business days to initiate IDR
- Step 4
IDR is initiated
The initiating party submits a notice of IDR initiation through the federal IDR portal and notifies the other party.
This is also when multiple claims can be batched into a single dispute, if they meet the federal batching requirements.
- 3 business days to select an IDR entity
- Step 5
IDR entity selection
The parties can jointly select a certified IDR entity (IDRE). If they can’t agree within the window, the Departments assign one. The non-initiating party can also raise an eligibility objection during the applicable response period.
- 3 business days for the IDRE to confirm no conflicts
- Step 6
Eligibility review
The IDRE confirms it has no conflict of interest and reviews whether the dispute qualifies for the federal IDR process. It may request additional information from either party.
An eligibility determination is not guaranteed simply because a dispute was accepted for submission through the portal.
- 10 business days from selection to submit offers
- Step 7
Offers and fees due
Both parties submit their final payment offers, supporting documentation, and required fees.
Each party pays a $15 administrative fee per dispute, plus the IDRE fees (see here for 2026 rates). An offer submitted without the required fees is treated as not received.
- 30 business days from selection to determination
- Step 8
Payment determination
The IDRE selects one party’s final offer. In batched disputes, determinations may differ across line items.
The prevailing party’s IDRE fee is refunded. The plan has 30 calendar days to pay the determined amount, less any initial payment and applicable patient cost-sharing.
- Cooling-off period begins
- Step 9
Cooling-off period
The initiating party can’t start another dispute against the same party for the same item or service during the cooling-off period. Claims that fall within it may be submitted once it ends.
Single disputes: 90 calendar days. Qualifying batched disputes with open negotiation beginning on or after November 1, 2026: 30 business days.
IDR benchmarks for emergency medicine
How does your claim compare with other emergency medicine disputes? Filter historical outcomes by CPT code, state, and payor to see how often providers prevail, where determinations fall relative to the QPA, and how long the process takes.
If your offer sits well outside the range of historical determinations, have evidence that explains why. Results reflect past determinations and don’t predict the outcome of any individual dispute.
Benchmark explorer
What to watch out for
Understanding the IDR process is one thing. Navigating its operational nuances is another. Here are a few areas where emergency medicine groups should pay close attention.
Batching code flexibility is limited
Since November 1, 2026, anesthesiology, radiology, pathology, and laboratory services can be batched across qualifying Category I CPT code ranges. Emergency medicine is not included in that expanded flexibility.
Emergency groups will still need to follow the existing code-specific batching requirements. Fortunately, their claim volumes are often high enough to make code-specific batches worthwhile.
Downcoding appeals put IDR at risk
Downcoding is a pervasive challenge in emergency medicine. Some major payors have policies that target higher-level emergency department visits, reducing reimbursement by assigning a lower evaluation and management level than the physician originally billed.
Providers can appeal these decisions, but appeals can take months and multiple rounds. Meanwhile, the IDR filing window continues to run.
In some cases, pursuing an appeal before IDR may put the opportunity to dispute the payment at risk. Groups need to understand the applicable deadlines and evaluate the best path for each claim.
Contracts can follow the physician
Some payors contract with individual physicians rather than groups. That creates a potential eligibility problem when a physician joins a new group after previously working for an in-network practice.
A payor may challenge the claim by producing the physician’s former contract, even if the current group has no agreement with that plan.
Because emergency physicians frequently move between groups, don’t assume network status based on the group’s contracts alone. Verify each physician’s status with each plan before filing.
Frequently asked questions
What does IDR cost, and who pays the fees?
Both parties pay a non-refundable $15 administrative fee per dispute. Each also pays the IDR entity’s fee up front, and the prevailing party’s fee is refunded after the determination. In batched disputes where each side wins some line items, that fee may be split. Both fees are due when final offers are submitted.
Then there’s the cost of running the process itself: screening eligibility, managing open negotiation, building offers and tracking payments. Our IDR build vs. buy guide breaks down what that work involves and the tradeoffs of handling IDR in-house or with a partner.
How do you know if a claim belongs in a state process or the federal one?
It usually comes down to the patient’s health plan, although some states can be more complicated. In states with their own surprise billing laws, fully insured plans are generally subject to the state process, while self-funded employer plans typically fall under the federal one. Some states also let self-funded plans opt in to the state process, and the scope of each state’s law varies.
The challenge is that payors often don’t make a plan’s funding type clear on the claim or remittance. Groups often need to enrich claims with third-party data to confirm the plan type and make sure each dispute goes through the right process.
What happens if a payor doesn’t pay after we win?
Unfortunately, it’s a major industry problem. According to the Emergency Department Practice Management Association (EDPMA), 24% of IDR disputes that resulted in payments owed to providers were either unpaid or paid incorrectly within the deadline set by federal law.
Running IDR the right way helps. When a group submits only eligible claims and makes reasonable, well-supported offers, payors have fewer grounds to dispute or delay payment after the fact. Tracking every determination against the payment deadline and following up promptly matters too.
When payment still doesn’t arrive, groups can file a complaint through the federal No Surprises Help Desk, or with the state insurance regulator for fully insured plans. Legal action is typically a last resort.
Does using IDR hurt our chances of getting back in network?
Not if it’s done right. IDR doesn’t make being out of network desirable, but it does show, in real terms, what having no agreement costs the payor on eligible claims. When resolving those claims out of network consistently costs more than paying a competitive contracted rate, both sides have a reason to come back to the table.
IDR outcomes alone don’t set a fair contract rate, though. Because IDR uses baseball-style arbitration, groups should pair their results with Transparency in Coverage data on what payors pay comparable providers in the market. Together, they help define a realistic negotiating range.
Sources
- 1U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, No Surprises Act Third Report to Congress (February 2026).
- 2U.S. Government Accountability Office, Private Health Insurance: Provider Participation and Payments for Selected Services Before and After the No Surprises Act, GAO-26-107169 (February 2026).
- 3Nam D. Pham, Rate Expectations: Evaluating the Validity of the QPAs Reported Under the No Surprises Act (NDP Analytics, December 2025), funded by Americans for Fair Health Care.
